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Over the next few weeks…. Creatinine improved from 267 to 200 and stable Abnormal LFTs thought to be due to statins, improved after stopping statins Generalised weakness, stops cyclo in september Desperate to cut down steroids, reduced and stopped over the next few weeks Creatinine stable-200

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Immune complex disease Distinct histologic, clinical and prognostic characteristics Substantial overlap – 15 to 50% evolve from one form to another – suggested in several studies One pathological finding relatively specific to lupus is presence of tubuloreticular structures in glomerular endothelial cells

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Immunological tests Pts. with SLE synthesize a variety of different autoantibodies – many react to well characterized nuclear antigens Some antibodies also found in other CTD 3 antinuclear antibodies diagnostically useful – anti-DNA; anti-Sm; and anti-RNP

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Membranous lupus Optimal therapy uncertain Asymptomatic patients often not treated;those with moderate disease may be treated with prednisolone Those with worsening renal functions or marked NS treated with same regimen as DPLN NIH study comparing cyclophosphamide or cyclosporin to prednisolone

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Membranous lupus Combination therapy with steroids and chlorambucil may be beneficial Retrospective study by Ponticelli group – 8 pts in the methypred and 11 pts in methylpred/chlorambucil 7 of 8 pts in steroid alone group had flares and 3 had complete or partial remission after 114 months mean f/u 1 of 11 in comination therapy group had flare and 10 had complete or partial remission after 83 mos mean f/u

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NIH study During maintanance – 5 pts died(4 in cyclo group/1 in MMF),CRF in 5(3 in cyclo/1 each in Aza and MMF) 72 month event free survival rate for composite end point of death or CRF higher for MMF and Aza groups Rate of relapse free survival higher in MMF group Incidence of hospitalization, amenorrhoea, infections was significantly lower in MMF and Aza groups

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More evidence for MMF Hong Kong group – JASN,Feb 2005 Extended long-term study, with median f/u of 63 mos Role of MMF as continuous induction- maintenance tretment for DPLN 33 pts. in MMF arm and 31 pts. In cyclo/Aza arm both in combination with prednisolone

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More evidence for MMF Complete or partial remission in 90% in each group Improvement in serology and proteinuria comparable between both groups Relapse- free survival and hazard ratio for relapse similar Fewer infections with MMF 4 pts in cyclo/Aza as compared to 1in MMF reached composite end point of death or CRF

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Conclusions 1 Renal involvement common in lupus Diagnosis of lupus nephritis based on a combination of renal bx and immunological tests Anti-ds DNA most useful test for diagnosis and monitoring of disease activity

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Conclusions 2 Immunosuppressive treatment for class IIIb,IV and some cases of V DPLN poorest prognosis Cyclophosphamide and steroid based regimens traditionally Very good latest evidence for MMF with less side-effect profile Rituximab seems promising